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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I,";TERFILE RECORD INFORMATION FOIA <br /> SHArED SECTIONS FOR EHD USE ONLY OWNER ID# CASE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOwINGBUSINESS OWNER INFORMATION; CHEcKrf OWNER CURREtmYONFILEwTTHEHD❑ <br /> BUSINESS HONE' <br /> OWNERS NAME l ) <br /> First MI Last <br /> BUSINESS NAME(V different from Ow r Name) SOC Sec orTax ID# <br /> OWNER'S HOME ADDRESS G 3 "L�4 S� S, (/S'f"/N <br /> CITY / Q„/ /` STATE zip . S� <br /> OWNER'S MAILING ADDRESS(if different from Owner's Address) Attention or Care of V <br /> MAILING ADDRESS CITY $TATE ZIP <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDMDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACIt]TY ID# ft - -' o=QwN ID#_- --= ACCOUNT ID#: <br /> COMPLETE THE FOLLOWINGBUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION Or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FACILITY NAME(This will be a BUszmss mEon the HEALTH PERMIT) <br /> C <br /> FACILITY ADDR F j�M Fcco WTor Foto VaunEuse a rnMt Y ADDRESS) BUSIN PHONE <br /> 2 /g vsr//v / <br /> ftmber Virecoon 5&eet Nance 5tmyt Tkpe Suite# <br /> CITY(If FAULITYts a LE FboD UNTorfboD VEHtCUE use the COMMISSARY Cm) ST ZIP l r' <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 !EY2 <br /> MAILING ADDRESS for Health Perm/t(If DiFFERENTfrom FaaldyAddress) Attention or Care CN <br /> MAILING ADDRESS CITY STATE ZIP <br /> it;.CQbE. :. "N#: Cofer <br /> AernLINTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that i am the Owner,Operator,or Authorized Agent of this Business,and <br /> acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address Identified above as the ACCOUNTADDRESS for this site. I also certify that all Information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED) <br /> "tleae, itp ` ' Daft <br /> t <br /> A PROGRAM {EHD 48-d-014 Pink} or WATER 9YSTEM {EHD 46-02-003} form must be completed for each EHD regulated operation at this <br /> LOCATION except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />